Research shows that any shift longer than 16 hours puts doctors and patients at risk.
“This must be a victory?” a radio presenter recently half-asked, half-stated. It was in response to the Western Cape health department’s announcement of a continuous work shift limit for medical interns. The presenter was interviewing a member of the Safe Working Hours campaign, which advocates for more reasonable working hours for young doctors. Medical interns have been expected to work 30-hour shifts.
Shortly after the interview, the Health Professions Council of South Africa (HPCSA), without much fanfare, confirmed that it would be introducing a 26-hour shift limit for interns. This is a major milestone, as regulation change is long overdue.
Through its proposed 26-hour cap, the HPCSA aspires to minimal disruption of the status quo. But this proposition blithely disregards the large body of evidence which indicates that exceeding 24 hours (and even, 16 hours) on a shift increases medical errors, needle-stick injuries and the risk of motor vehicle accidents.
The South African Medical Assocation has joined the fray with their “Employ More Doctors” campaign. Part of this drive is to issue all doctors with colour-coded armbands to indicate whether their level of fatigue makes them unsafe. Red for more than 30 hours, orange for 24 to 30 hours and, (alarmingly) green for 0 to 24 hours. The noble intentions of the campaign, are unfortunately hampered by their insistence that individuals can remain alert and effective up to the 24 hour mark. Although 24 hours has been touted as a limit in the past, one would be hard pressed to find evidence that describes persons approaching 24 hours of wakefulness as “optimal”.
Safer working hours require a paradigm shift away from a single team covering a full day and night towards teams managing care in realistic chunks of no more than 16 hours. Safe shift work expertise already exists in other disciplines, and health departments would be wise to enlist industrial engineers and others in ensuring truly safe working hours.
In 1977, James Proschaka and Carlos Di Clemente developed a fancily named “transtheoretical” model to be applied to health behaviour change. While commonly used for individuals and their habits, such as smoking and other substance use, the framework offers a useful schema to approach the medical profession’s pathological relationship to unsafe working hours.
Individuals can move between the stages of pre-contemplation (there is no problem), contemplation (okay, there is a problem, but change is not possible), preparation (things might need to change), action (let’s do this), maintenance (keeping the problem under control), and either permanent exit (problem solved) or relapse to any of the previous stages (here we go again).
Much of the response to the Safe Working Hours campaign has been positive and supportive, and this reflects that many are ready to take action. Indeed, several stories of departments in selected hospitals applying safer working hours (shorter shifts with more stringent hand-over) have made their way to safe working hours. These hospitals have elected not to wait for their respective provinces or the HPCSA, and have taken it upon themselves to make working hours safe for patients and practitioners.
In light of this groundswell of support, it is difficult to understand voices of dissent from within the medical profession which announce themselves through social media, denying that long continuous shifts are an issue at all.
The segmentation of the medical profession into a cornucopia of transitional phases through which a layperson is transmuted into a medical student, intern, medical officer, registrar, and finally consultant, contributes to group identities, which (by design or by accident) sometimes end up with competing interests in the workplace. This takes place within a much larger struggle where certain unpleasant tasks in the workplace are sometimes slugged to and fro between and within professions whenever possible.
Patient care may well take a back seat to internal squabbles about who needs to book the scan, do the procedure, and who can sleep while the others work.
The rigid medical hierarchy and the vulnerability of the most junior professionals lead, in some instances, to problematic behaviour towards junior staff and other personnel. Such an instance was recently exposed when former intern Yumna Moosa’s intimidation and harassment at the hands of several of her supervisors were exposed in audio recordings. She was threatened and further pressured to recant complaints about her working environment and superiors and it appears that allegations of incompetence were fabricated to discredit her.
When conflict arises around an issue where certain influential senior professionals are in pre-contemplation and while many junior professionals are in the preparation and action phases, tensions begin to rise.
“Now we are going to have to pick up your slack.” This comment, from a senior colleague to a fellow intern after the Western Cape’s announcement of an upcoming 24-hour cap for junior doctors’ shifts, illustrates the zero-sum and us-vs-them thinking around many of the issues in the working environment.
An intern or junior doctor shift cap is, and can only be, a precursor to a profession-wide cap on continuous shifts. Safe working hours are in the interest of patient safety and should not be limited to one subgroup of doctors. It makes no sense to reduce only intern working hours and then expect the rest of the team to continue to work inhuman shifts. There is no magical point in one’s career at which fatigue ceases to be an impairment.
A continuous shift limit for all doctors strongly encourages departments to change, introduce shift systems and pre-call rest periods whilst fostering awareness of human limitations and egalitarianism between different members of the team.
The Western Cape Department of Health has entered the preparation phase and will hopefully go through with its New Years’ resolution. The HPCSA and National Department of Health are contemplating cutting down on unsafe working hours, but are still mulling the matter over.
Yet for hospital managers and heads of department, there is no need to wait for the regulators to alter the allowable maximums. The public and doctors have jointly indicated that things cannot continue as they are, and the regulators are finally paying attention. The time for action is now.
Koot Kotze is a medical doctor working as an intern at an Eastern Cape hospital. He is a founding member of Safe Working Hours campaign.